Glycaemic/metabolic control; CV risk reduction
Uncontrolled type 2 diabetes, metabolic syndrome, NASH, Increased CV risk
Traditional (RYGB, SG, BPD, LAGB)
Traditional (RYGB, SG, BPD, LAGB)
Investigational (DJB, IT endoscopic duodenal sleeve)
Measures of outcome
Weight loss (excess weight loss)
Glycaemic control, blood pressure, lipid control, CV risk reduction, weight loss
Presumed mechanisms of action
Restriction to food intake/malabsorption
Several, complex, neuroendocrine
9.6 Diabetes Surgery: Current Priorities and Future Directions
The development of proper diabetes surgery implies a number of transformative changes to the model of care of traditional bariatric surgery. Traditional bariatric surgery practice in fact does not include accurate diagnostics measures of diabetes, evaluation of residual pancreatic function or careful screening for micro- and macrovascular complications of diabetes. Fasting insulin levels are not a mandatory routine test in most centers of excellence for bariatric surgery. This traditional practice is largely responsible for our current inability to accurately predict outcomes of bariatric surgery on diabetes based on preoperative patients’ characteristics.
Appropriate therapeutic strategies should also be developed to optimize diabetes and metabolic control. For instance, preoperative medical/dietary interventions should be considered when appropriate to improve preoperative glycaemic control. Protocols for continuation of medical therapy after surgery should be tailored to complement mechanisms of action of specific operations, introducing the concept of “adjuvant” medical therapy after surgical or device-based gastrointestinal interventions.
Finally, development of appropriate disease-based criteria for selection of surgical candidates rather than mere “weight-centric” criteria should be implemented, including measures of risks-stratification, predicting factors of success and failure, lack of responsiveness to medical and lifestyle interventions.
The novel field of diabetes surgery has emerged from a surgical discipline initially focused primarily on weight loss. Surgery offers a unique opportunity for remission or improved control of type 2 diabetes and could potentiate traditional therapy by lifestyle and pharmaceutical interventions. It is envisaged that ongoing RCTs and future studies will help identify the best candidates for surgical treatment among the vast population of diabetic patients, including the less obese. Furthermore, mechanistic studies aimed at using gastrointestinal surgery to elucidate the role of the gut in glucose homeostasis may possibly uncover new targets and molecules for future less invasive therapeutic approaches of curative intent.
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